Survey Report for 921766

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	921766	A. BUILDING __________ B. WING ______________	02/16/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
UNICARE HOSPICE PROVIDER, INC	870 N MOUNTAIN AVE, SUITE 208, UPLAND, CA, 91786
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0520
L0520	35183 The agency failed to ensure that the Condition of Participation: L 520 418.54 Initial and Comprehensive assessment of the patient was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure the patients' initial assessment was completed within 48 hours of the patients' election of hospice care for four of six sampled patients (Patients 1, 2, 3, and 6). (Refer to L 522) 2. Based on interview and record review, the agency failed to ensure the patients' comprehensive assessments were completed within five days after the election of hospice care for six of six sampled patients (Patient 1, 2, 3, 4, 5 and 6) when: 2a. For Patient 1, no initial psychosocial or bereavement assessment was completed. (Refer to L 523) 2b. For Patient 2, the initial spiritual assessment was completed in six days, the initial psychosocial assessment was completed in nine days and no initial bereavement assessment was completed. (Refer to L 523) 2c. For Patient 3, no initial bereavement assessment was completed. (Refer to L 523) 2d. For Patient 4, no initial bereavement assessment was completed. (Refer to L 523) 2e. For Patient 5, the initial psychosocial assessment was completed in 10 days and no initial bereavement assessment was completed. (Refer to L 523) 2f. For Patient 6, the initial psychosocial assessment was not completed and no initial bereavement assessment was completed. (Refer to L 523) 3. Based on observation, interview, and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for three of six sampled patients (Patients 3, 4, and 5) when: 3a. For Patient 3, a thyroid medication's administration instructions on the medication profile (MP-a current list of all medications prescribed for a specific patient), indicated a dosage of ten times the amount indicated on the bottle's pharmacy label, one medication the patient was taking was not indicated on the MP and one medication on the MP, the patient was not taking. (Refer to L 530) 3b. For Patient 4, three medications, indicated on the MP, the patient was not taking, and three medications the patient was taking, were not indicated on the MP. (Refer to L 530) 3c. For Patient 5, a blood thinning medication's administration instructions on the MP indicated a dosage of three times the amount indicated on the bottle's pharmacy label and oxygen was indicated on the MP as continuous administration when the patient used oxygen only as needed. (Refer to L 530) 4. Based on interview and record review, the agency failed to ensure the initial bereavement assessment was completed at the time of admission to hospice for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6). (Refer to L 531) The cumulative effect of these systemic practices resulted in the potential to cause: a delay in the determination of Patients 1, 2, 3 and 6's immediate care and support needs; the patient and family's psychosocial, emotional and spiritual needs to go unmet; Patient 3 to suffer hyperthyroidism (a condition of too much thyroxine hormone with side effects that include unexpected weight loss, rapid or irregular heartbeat, sweating, and irritability); Patient 4 to suffer ineffective drug therapy, significant side effects and noncompliance with drug therapy and Patient 5 to suffer an overdose of a blood thinning medication with side effects that include: long or excessive bleeding, exceptional weakness, tiredness, paleness, dizziness, headache or unexplained swelling and family members'/significant others' bereavement needs to go unmet and to suffer unrecognized pathological grief reactions (prolonged grief which significantly and functionally impairs an individual's day to day life).
L0522
L0522	35183 Based on interview and record review, the agency failed to ensure the patients' initial assessment was completed within 48 hours of the patients' election of hospice care for four of six sampled patients (Patients 1, 2, 3, and 6). This failure had the potential to cause a delay in the determination of Patients 1, 2, 3 and 6's immediate care and support needs. Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 18, 2020, with a certification period of September 18, 2020 to December 16, 2020. Patient 1 had diagnoses that included cancer of the jaw. A review of Patient 1's election of hospice care, dated September 17, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 17, 2020." A review of Patient 1's initial admission assessment indicated a visit date of September 21, 2020. Four days had passed from the date of the election of hospice care, to the admission of Patient 1. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of October 3, 2020, with a certification period of October 3, 2020 to December 31, 2020. Patient 2 had diagnoses that included end stage renal disease (the kidneys stop functioning). A review of Patient 2's election of hospice care, dated September 29, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 29, 2020." A review of Patient 2's initial admission assessment indicated a visit date of October 5, 2020. Six days had passed from the date of the election of hospice care, to the admission of Patient 2. 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 5, 2020, with a recertification period of December 4, 2020 to March 3, 2021. Patient 3 had diagnoses that included hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone). A review of Patient 3's election of hospice care, dated September 5, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 5, 2020." A review of Patient 3's initial admission assessment indicated a visit date of September 8, 2020. Three days had passed from the date of the election of hospice care, to the admission of Patient 3. 4. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 10, 2020, with a certification period of November 10, 2020 to January 27, 2021. Patient 6 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 6's election of hospice care, dated November 7, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective November 7, 2020." A review of Patient 6's initial admission assessment indicated a visit date of November 10, 2020. Three days had passed from the date of the election of hospice care, to the admission of Patient 6. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 from 12:14 PM to 12:56 PM, the DPCSD stated Patients 1, 2, 3, and 6's initial assessments were not conducted within 48 hours of the election of hospice care. The DPCSD stated he thought the initial assessment was to be conducted within 48 hours of the patients' start of care. The DPCSD stated after reviewing the agency's policy and procedure he realized this was incorrect. A review of the agency's policy and procedure titled, "Initial Assessment," dated April 2013, indicated, "Policy: An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient or representative to be completed in less than 48 hours."
L0523
L0523	35183 CA00714103 Based on interview and record review, the agency failed to ensure the patients' comprehensive assessments were completed within five days after the election of hospice care for six of six sampled patients (Patient 1, 2, 3, 4, 5 and 6) when: 1. For Patient 1, no initial psychosocial or bereavement assessment was completed. 2. For Patient 2, the initial spiritual assessment was completed in six days, the initial psychosocial assessment was completed in nine days and no initial bereavement assessment was completed. 3. For Patient 3, no initial bereavement assessment was completed. 4. For Patient 4, no initial bereavement assessment was completed. 5. For Patient 5, the initial psychosocial assessment was completed in 10 days and no initial bereavement assessment was completed. 6. For Patient 6, the initial psychosocial assessment was not completed and no initial bereavement assessment was completed. This failure had the potential to cause the patient and family's psychosocial, emotional and spiritual needs to go unmet. Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 18, 2020, with a certification period of September 18, 2020 to December 16, 2020. Patient 1 had diagnoses that included cancer of the jaw. Patient 1 transferred to another hospice agency on September 24, 2020. A review of Patient 1's election of hospice care, dated September 17, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 17, 2020." A review of Patient 1's initial admission assessment indicated a visit date of September 21, 2020. A review of Patient 1's Medical Social Worker's (MSW 1) visit notes from September 17, 2020 to September 24, 2020 was conducted. There was no documented evidence to show an initial psychosocial assessment or bereavement assessment had been conducted. MSW 1 had left the agency's employ on September 30, 2020. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of October 3, 2020, with a certification period of October 3, 2020 to December 31, 2020. Patient 2 had diagnoses that included end stage renal disease (the kidneys stop functioning). Patient 2 passed away on October 23, 2020. A review of Patient 2's election of hospice care, dated September 29, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 29, 2020." A review of Patient 2's initial admission assessment indicated a visit date of October 5, 2020. A review of Patient 2's Medical Social Worker's (MSW 2) visit notes from September 29, 2020 to October 23, 2020 was conducted. Patient 2's initial psychosocial assessment was dated October 8, 2020, nine days after the election of hospice care. There was no documented evidence to show an initial bereavement assessment had been conducted. A review of Patient 2's Spiritual Counselor's (SC 1) visits notes from September 29, 2020 to October 23, 2020 was conducted. Patient 2's initial spiritual assessment was dated October 5, 2020, six days after the election of hospice care. During an interview with SC 1 on February 11, 2021 at 2:11 PM, SC 1 stated, "I have been with the agency for two years." SC 1 stated he did not know he had to complete the initial spiritual assessment within five days of the patient's election of hospice care. SC 1 confirmed he did not complete the initial spiritual assessment for Patient 2 within five days of the patient's election of hospice care. MSW 2 had left the agency's employ on January 29, 2021. 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 5, 2020, with a recertification period of December 4, 2020 to March 3, 2021. Patient 3 had diagnoses that included hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone). A review of Patient 3's election of hospice care, dated September 5, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 5, 2020." A review of Patient 3's initial admission assessment indicated a visit date of September 8, 2020. A review of Patient 3's Medical Social Worker's (MSW 1) visit notes from September 5, 2020 to February 16, 2021 was conducted. There was no documented evidence to show an initial bereavement assessment had been conducted. MSW 1 had left the agency's employ on September 30, 2020. 4. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 9, 2021, with a certification period of January 9, 2021 to March 9, 2021. Patient 4 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 4's election of hospice care, dated January 8, 2021, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective January 8, 2021." A review of Patient 4's initial admission assessment indicated a visit date of January 9, 2021. A review of Patient 4's Medical Social Worker's (MSW 2) visit notes from January 8, 2021 to February 16, 2021 was conducted. There was no documented evidence to show an initial bereavement assessment had been conducted. MSW 2 had left the agency's employ on January 29, 2021. 5. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 6, 2020, with a certification period of December 6, 2020 to March 5, 2021. Patient 5 had diagnoses that included deep vein thrombosis (DVT-a blood clot in a vein lying deep below the skin, especially in the legs). A review of Patient 5's election of hospice care, dated December 4, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective December 4, 2020." A review of Patient 5's initial admission assessment indicated a visit date of December 6, 2020. A review of Patient 5's Medical Social Worker's (MSW 2) visit notes from December 4, 2020 to February 16, 2021 was conducted. Patient 2's initial psychosocial assessment was dated December 14, 2020, 10 days after the election of hospice care. There was no documented evidence to show an initial bereavement assessment had been conducted. MSW 2 had left the agency's employ on January 29, 2021. 6. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 10, 2020, with a certification period of November 10, 2020 to January 27, 2021. Patient 6 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 6's election of hospice care, dated November 7, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective November 7, 2020." A review of Patient 6's initial admission assessment indicated a visit date of November 10, 2020. A review of Patient 6's Medical Social Worker's (MSW 2) visit notes from November 7, 2020 to February 16, 2021 was conducted. There was no documented evidence to show an initial psychosocial assessment or bereavement assessment had been conducted. MSW 2 had left the agency's employ on January 29, 2021. During an interview with a Medical Social Worker (MSW 3) on February 11, 2021 at 1:58 PM, MSW 3 stated she had started work at the agency on February 1, 2021. MSW 3 stated she was unaware she was supposed to conduct initial bereavement assessments at the patients' admissions. MSW 3 stated she thought she was supposed to conduct initial psychosocial assessments within five days of the patient's start of care, not within five days of the patient's election of care. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 from 12:14 PM to 12:56 PM, the DPCSD stated he did not know the initial spiritual and psychosocial assessments needed to be completed within five days of the patients' election of hospice care. The DPCSD stated he thought it was within five days of the patients' start of care date. The DPCSD verified that Patients 1, 2, 3, 4, 5, and 6 did not have a completed comprehensive assessment within five days of the patients' election of hospice care. The DPCSD stated Patients 1, 2, 3, 4, 5, and 6 did not receive an initial bereavement assessment. The DPCSD stated it was the Medical Social Worker's (MSW 1 and MSW 2) responsibility to conduct the initial bereavement assessments for Patients 1, 2, 3, 4, 5, and 6, but they did not. The DPCSD stated he was unaware that the assessments were not being done. A review of the agency's policy and procedure titled, "Comprehensive Assessment," dated April 2013, indicated the following: "Purpose: To provide guidelines for the comprehensive assessment. Policy: A comprehensive patient assessment will be performed by the hospice IDG [Interdisciplinary Group] no later than 5 [five] calendar days after the election of hospice care in consultation with attending physician."
L0530
L0530	35183 Based on observation, interview, and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for three of six sampled patients (Patients 3, 4, and 5) when: 1. For Patient 3, a thyroid medication's administration instructions on the medication profile (MP-a current list of all medications prescribed for a specific patient), indicated a dosage of ten times the amount indicated on the bottle's pharmacy label, one medication the patient was taking was not indicated on the MP and one medication on the MP, the patient was not taking. 2. For Patient 4, three medications, indicated on the MP, the patient was not taking, and three medications the patient was taking, were not indicated on the MP. 3. For Patient 5, a blood thinning medication's administration instructions on the MP indicated a dosage of three times the amount indicated on the bottle's pharmacy label and oxygen was indicated on the MP as continuous administration when the patient used oxygen only as needed. This failure had the potential to cause Patient 3 to suffer hyperthyroidism (a condition of too much thyroxine hormone with side effects that include unexpected weight loss, rapid or irregular heartbeat, sweating, and irritability); Patient 4 to suffer ineffective drug therapy, significant side effects and noncompliance with drug therapy and Patient 5 to suffer an overdose of a blood thinning medication with side effects that include: long or excessive bleeding, exceptional weakness, tiredness, paleness, dizziness, headache or unexplained swelling. Findings: 1. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 5, 2020, with a recertification period of December 4, 2020 to March 3, 2021. Patient 3 had diagnoses that included hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone). During a home visit on February 10, 2021 with a Licensed Vocational Nurse (LVN 5) and in the presence of Patient 3's daughter-in-law, an observation of Patient 3's actual medication bottles available in the home were compared with Patient 3's Medication Profile (MP - a current list of all medications prescribed for a specific patient). During an observation and concurrent interview with Patient 3's daughter-n-law and LVN 5 on February 10, 2021 at 10:57 AM, LVN 5 supplied a bottle of levothyroxine (a medication that replaces thyroid hormone) 25 mcg (micrograms-a unit of measure), take one tablet by mouth every day (date originally filled, November 13, 2020). Patient 3's MP indicated levothyroxine 250 mcg, take one tablet, oral (by mouth) daily. LVN 5 verified Patient 3's prescription bottle's label indicated 25 mcg and Patient 3's MP indicated 250 mcg. Patient 3's daughter-in-law stated she followed the instructions on the prescription bottle's label. During an observation and concurrent interview with Patient 3's daughter-n-law and LVN 5 on February 10, 2021 at 11:22 AM, LVN 5 supplied a bottle of mirtazapine (a medication that treats depression and increases appetite) 15 mg (milligrams-a unit of measure), take one tablet by mouth at bedtime. Patient 3's MP did not indicate mirtazapine. LVN 5 verified Patient 3 had a prescription bottle of mirtazapine and the mirtazapine was not indicated on Patient 3's MP. Patient 3's daughter-in-law stated Patient 3 had been taking the mirtazapine since the end of September 2020. During an observation and concurrent interview with Patient 3's daughter-n-law and LVN 5 on February 10, 2021 at 11:28 AM, Patient 3's MP indicated Topamax (a medication to prevent seizures) 100 mg (milligrams-a unit of measure) tablets, give two tablets at night, by mouth. LVN 5 verified Patient 3 did not have a prescription bottle of Topamax that indicated taking two tablets at night. Patient 3's daughter-in-law stated Patient 3 had not been taking two tablets of Topamax at night for 2 to 3 months. Patient 3's daughter-in-law stated Patient 3 took one tablet of Topamax in the morning. During an interview with LVN 5 on February 10, 2021 at 11:35 AM, LVN 5 stated this was the first time she had visited Patient 3 and did not know why Patient 3's MP was not current and accurate. LVN 5 stated it was her normal practice to check on the patients' medications at each of her visits. 2. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 9, 2021, with a certification period of January 9, 2021 to March 9, 2021. Patient 4 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). During a home visit on February 9, 2021 with a Registered Nurse (RN 1) and in the presence of Patient 4, an observation of Patient 4's actual medication bottles available in the home were compared with Patient 4's Medication Profile (MP - a current list of all medications prescribed for a specific patient). Patient 4's MP indicated the following medications: a. Albuterol (a medication to open airways in the lungs) HFA (a propellant called hydrofluoroalkane) inhaler (a portable device for administering a drug which was to be breathed in), 90 mcg (micrograms-a unit of measure), 2 (two) inhalations, every four hours, as needed. b. Cefuroxime axetil (an antibiotic used to treat an infection), 500 mg (milligrams-a unit of measure), one tablet, by mouth, every 12 hours, for a urinary tract infection. c. Miconazole cream (an antifungal medication), topical (on the skin), apply four times a day. During an observation and concurrent interview with RN 1 and Patient 4 on February 9, 2021 at 10:06 AM, RN 1 verified there were no containers of albuterol, cefuroxime axetil or miconazole cream in Patient 4's home. Patient 4 stated she had not used an albuterol inhaler since admission into hospice care. Patient 4 stated she had finished taking the cefuroxime axetil around the middle of January 2021 and Patient 4 stated she did not currently have a urinary tract infection. Patient 4 stated she had stopped using the miconazole cream last week, as it did not work. During an observation and concurrent interview with RN 1 and Patient 4 on February 9, 2021 at 10:32 AM, Patient 4 supplied the following medication containers: a. Senna (a laxative) 8.6 mg (milligrams-a unit of measure) tablets, take one tablet by mouth every day. b. Vitamin D-3 (a supplement) 2,000 IU (international unit-a unit of measure) in an over-the-counter bottle. c. Nystop (a medication to treat fungal infections) 10,000 unit/GM (units per gram-a unit of measure) powder, apply to affected area 3 (three) times a day. RN 1 verified the Senna, Vitamin D-3 and Nystop powder were not indicated on Patient 4's MP. Patient 4 stated she had been taking Senna since the beginning of December 2020. Patient 4 stated she had been taking Vitamin D for a long time, since before admission to the hospice. Patient 4 stated the Nystop powder was a new medication. During an interview with RN 1 on February 9, 2021 at 10:38 AM, RN 1 stated when she made visits to her patients, she would ask if they needed refills of any medications. RN 1 stated she did not review patient medications at her nursing visits. 3. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 6, 2020, with a certification period of December 6, 2020 to March 5, 2021. Patient 5 had diagnoses that included deep vein thrombosis (DVT-a blood clot in a vein lying deep below the skin, especially in the legs). During a home visit on February 9, 2021 with a Registered Nurse (RN 1) and in the presence of Patient 5's daughter, an observation of Patient 5's actual medication bottles available in the home were compared with Patient 5's Medication Profile (MP - a current list of all medications prescribed for a specific patient). During an observation and concurrent interview with Patient 5's daughter and RN 1 on February 9, 2021 at 3:41 PM, Patient 5's daughter supplied a bottle of Eliquis (a medication that thins the blood to prevent blood clots) 5 mg (milligrams-a unit of measure), take one-half tablet by mouth two times a day (a total of 5 mg each day). Patient 5's MP indicated Eliquis 5 mg tablet, take 1.5 tablets, oral (by mouth), twice a day (a total of 15 mg each day). RN 1 verified Patient 5's prescription bottle's label indicated one-half tablet and Patient 5's MP indicated 1.5 tablets. Patient 5's daughter stated she followed the instructions on the prescription bottle's label and gave a half a tablet two times per day. Patient 5's daughter stated Patient 5 had been taking Eliquis half a tablet, two times a day, since September 2018. RN 1 stated the MP indicated too much Eliquis. During an observation and concurrent interview with Patient 5, Patient 5's daughter and RN 1 on February 9, 2021 at 3:49 PM, Patient 5's MP indicated oxygen at 2 (two) liters per minute via nasal cannula (a device consisting of a lightweight tube which on one end splits into two prongs that are placed in the nostrils to deliver oxygen), continuously. An observation of Patient 5 showed no nasal cannula in place or oxygen concentrator machine in use. Patient 5's daughter stated Patient 5 did not use oxygen continuously. Patient 5's daughter stated she provided Patient 5 oxygen when she needed it. RN 1 verified Patient 5's MP indicated oxygen continuously and Patient 5 was not using oxygen continuously. During an interview with RN 1 on February 9, 2021 at 3:52 PM, RN 1 stated when she made visits to her patients, she would ask if they needed refills of any medications. RN 1 stated she did not review patient medications at her nursing visits. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 from 12:28 PM to 12:47 PM, the DPCSD stated the RNs who conducted Patient 3, 4 and 5's initial admission assessments did not complete an accurate drug regimen review. The DPCSD stated it was his expectation that every nurse who visited the patients, conduct a review of medications at each visit. The DPCSD stated, "Medication reviews are not being done and they should be." A review of the agency's policy and procedure titled, "Medication Profile," dated April 2013, indicated the following: "Purpose: To define the use of the medication profile in evaluating a patient's current medication regimen. Policy: Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Procedure: A drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: Using the medication profile to evaluate the use of the drugs in the home setting. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications. Using the medication profile as a communication tool for other clinicians involved in care." An Immediate Jeopardy (IJ-a situation with the potential to harm the health and safety of the patients) was called under 42 CFR 418.54(c)(6) L 530 Drug profile, on February 10, 2021 at 2:56 PM, in the presence of the Administrator (Admin) and Director of Patient Care Services (DPCS). The Administrator (Admin) and Director of Patient Care Services (DPCS) were verbally notified of the IJ situation identified based on the agency's failure to ensure the patients' medications were reviewed and an accurate medication profile was established that was free of significant medication errors. The agency submitted a corrective action plan which was reviewed and accepted on February 10, 2021 at 4:35 PM, in the presence of the Administrator (Admin), Director of Patient Care Services (DPCS) and Director of Patient Care Services Designee (DPCSD). The agency's corrective action plan indicated the following: "Pre-Admit Evaluation Effective today [February 10, 2021] [Name of agency] will start a policy of no hospice admission/soc [start of care] until a patient is seen by a Registered Nurse. After hours/weekend admissions/holidays or at any time, if no available Registered Nurse, DPCS will do the admission for the patient in its entirety. A Registered Nurse position for after hours and admissions. 3 [three] applicants at this time. Will be filled ASAP [as soon as possible]. No Licensed Vocational Nurse will be doing pre-admit evaluation. Medication Reconciliation: Will only be done by admitting Registered Nurse during initial assessment and re-certification assessments. Within 48 hours, Registered Nurse Case manager who is assigned to the patient will check medications that were reconciled by admitting Registered Nurse and Registered Nurse Case Manager needs to complete comprehensive assessment. Registered Nurse Case Manager will review and reconcile medications during IDT [Interdisciplinary Team Meetings] with Hospice Physician. Registered Nurse Case Manager will reconcile medications every visit. In-services about medication profile policy to all Registered Nurses and Licensed Vocational Nurses will be re-educated about scope of practice. Random visits by the PCC [Patient Care Coordinator]/DPCS will be done every month to check any discrepancies for patients (25% patients of current census will be seen). DPCS will check and reconcile medications. PCC will compare medications on hand to current...medication profile, any discrepancies DPCS will be notified and incident report. Mandatory meeting will be done today [February 10, 2021] with all licensed nursing staff. Currently there is no scheduled admissions." After interviews with randomly selected Registered Nurses and Licensed Vocational Nurses on re-training and a review of updated agency policy and procedures, the IJ was lifted on February 11, 2021 at 3:36 PM, in the presence of the Administrator (Admin), Director of Patient Care Services (DPCS) and Director of Patient Care Services Designee (DPCSD).
L0531
L0531	35183 Based on interview and record review, the agency failed to ensure the initial bereavement assessment was completed at the time of admission to hospice for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6). This failure had the potential to cause family members'/significant others' bereavement needs to go unmet and to suffer unrecognized pathological grief reactions (prolonged grief which significantly and functionally impairs an individual's day to day life). Findings: 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 18, 2020, with a certification period of September 18, 2020 to December 16, 2020. Patient 1 had diagnoses that included cancer of the jaw. Patient 1 transferred to another hospice agency on September 24, 2020. A review of Patient 1's election of hospice care, dated September 17, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 17, 2020." A review of Patient 1's initial admission assessment indicated a visit date of September 21, 2020. A review of Patient 1's Medical Social Worker's (MSW 1) visit notes from September 17, 2020 to September 24, 2020 was conducted. There was no documented evidence to show an initial bereavement assessment had been conducted. MSW 1 had left the agency's employ on September 30, 2020. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of October 3, 2020, with a certification period of October 3, 2020 to December 31, 2020. Patient 2 had diagnoses that included end stage renal disease (the kidneys stop functioning). Patient 2 passed away on October 23, 2020. A review of Patient 2's election of hospice care, dated September 29, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 29, 2020." A review of Patient 2's initial admission assessment indicated a visit date of October 5, 2020. A review of Patient 2's Medical Social Worker's (MSW 2) visit notes from September 29, 2020 to October 23, 2020 was conducted. There was no documented evidence to show an initial bereavement assessment had been conducted. MSW 2 had left the agency's employ on January 29, 2021. 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 5, 2020, with a recertification period of December 4, 2020 to March 3, 2021. Patient 3 had diagnoses that included hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone). A review of Patient 3's election of hospice care, dated September 5, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 5, 2020." A review of Patient 3's initial admission assessment indicated a visit date of September 8, 2020. A review of Patient 3's Medical Social Worker's (MSW 1) visit notes from September 5, 2020 to February 16, 2021 was conducted. There was no documented evidence to show an initial bereavement assessment had been conducted. MSW 1 had left the agency's employ on September 30, 2020. 4. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 9, 2021, with a certification period of January 9, 2021 to March 9, 2021. Patient 4 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 4's election of hospice care, dated January 8, 2021, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective January 8, 2021." A review of Patient 4's initial admission assessment indicated a visit date of January 9, 2021. A review of Patient 4's Medical Social Worker's (MSW 2) visit notes from January 8, 2021 to February 16, 2021 was conducted. There was no documented evidence to show an initial bereavement assessment had been conducted. MSW 2 had left the agency's employ on January 29, 2021. 5. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 6, 2020, with a certification period of December 6, 2020 to March 5, 2021. Patient 5 had diagnoses that included deep vein thrombosis (DVT-a blood clot in a vein lying deep below the skin, especially in the legs). A review of Patient 5's election of hospice care, dated December 4, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective December 4, 2020." A review of Patient 5's initial admission assessment indicated a visit date of December 6, 2020. A review of Patient 5's Medical Social Worker's (MSW 2) visit notes from December 4, 2020 to February 16, 2021 was conducted. There was no documented evidence to show an initial bereavement assessment had been conducted. MSW 2 had left the agency's employ on January 29, 2021. 6. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 10, 2020, with a certification period of November 10, 2020 to January 27, 2021. Patient 6 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 6's election of hospice care, dated November 7, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective November 7, 2020." A review of Patient 6's initial admission assessment indicated a visit date of November 10, 2020. A review of Patient 6's Medical Social Worker's (MSW 2) visit notes from November 7, 2020 to February 16, 2021 was conducted. There was no documented evidence to show an initial bereavement assessment had been conducted. MSW 2 had left the agency's employ on January 29, 2021. During an interview with a Medical Social Worker (MSW 3) on February 11, 2021 at 1:58 PM, MSW 3 stated she had started work at the agency on February 1, 2021. MSW 3 stated she was unaware she was supposed to conduct initial bereavement assessments at the patients' admissions. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 from 12:14 PM to 12:56 PM, the DPCSD stated Patients 1, 2, 3, 4, 5, and 6 did not receive an initial bereavement assessment. The DPCSD stated it was the Medical Social Worker's (MSW 1 and MSW 2) responsibility to conduct the initial bereavement assessments for Patients 1, 2, 3, 4, 5, and 6, but they did not. The DPCSD stated he was unaware that the assessments were not being done. A review of the agency's policy and procedure titled, "Bereavement Services," dated April 2013, indicated the following: "Purpose: To ensure that appropriate and coordinated bereavement services are provided to family/caregivers. Policy: ...The program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient's death, in accordance with the plan of care. The purpose of these services will be to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. The purpose will also be to prepare the individual to function independently of hospice and to identify a support system with the individual. Procedure: A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care."
L0536
L0536	35183 The hospice agency failed to ensure the Condition of Participation L 536 418.56: Interdisciplinary group, care planning, and coordination of services was in compliance as follows: 1. Based on interview and record review, the agency failed to ensure the patients' plan of care was followed for two of six sampled patients (Patient 2 and 5) when: a. For Patient 2, the Hospice Aide (HA) did not make visits as ordered. (Refer to L 543) b. For Patient 5, the Skilled Nurse (SN), Hospice Aide (HA), Spiritual Counselor (SC) and Medical Social Worker (MSW) did not make visits as ordered. (Refer to L 543) 2. Based on interview and record review, the agency failed to develop an individualized plan of care for four of six sampled patients (Patients 3, 4, 5 and 6) when: a. For Patient 3, there were no physician's orders for Skilled Nursing (SN), Hospice Aide (HA), Spiritual Counselor (SC) or Medical Social Worker (MSW) visits. (Refer to L 545) b. For Patient 4, a Licensed Vocational Nurse (LVN) conducted a pre-admission assessment in the patients' home, without a physician's order. (Refer to L 545) c. For Patient 5, a Licensed Vocational Nurse (LVN) conducted a pre-admission assessment in the patients' home, without a physician's order. (Refer to L 545) d. For Patient 6, a Licensed Vocational Nurse (LVN) conducted a pre-admission assessment in the patients' home without a physician's order and there was no physician's order for Medical Social Worker (MSW) visits. (Refer to L 545) The cumulative effect of these systemic practices resulted in the potential to cause: Patient 2 and 5 not to progress toward palliative (to make the effects of a disease less severe) goals that increase the patients' quality of life and mitigate (ease) suffering and Patients 3, 4, 5 and 6 to receive care and services without a physician's clinical oversight.
L0543
L0543	35183 Based on interview and record review, the agency failed to ensure the patients' plan of care was followed for two of six sampled patients (Patient 2 and 5) when: 1. For Patient 2, the Hospice Aide (HA) did not make visits as ordered. 2. For Patient 5, the Skilled Nurse (SN), Hospice Aide (HA), Spiritual Counselor (SC) and Medical Social Worker (MSW) did not make visits as ordered. This failure had the potential to cause Patient 2 and 5 not to progress toward palliative (to make the effects of a disease less severe) goals that increase the patients' quality of life and mitigate (ease) suffering. Findings: 1. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of October 3, 2020, with a certification period of October 3, 2020 to December 31, 2020. Patient 2 had diagnoses that included end stage renal disease (the kidneys stop functioning). Patient 2 passed away on October 23, 2020. A review of Patient 2's plan of care/physician's order dated October 3, 2020, indicated, "Frequency of visit: CHHA [Certified Home Health Aide] 3 [three] x [times] [a] week for personal care and assistance. A review of Patient 2's Hospice Aide (HA) visit notes from October 3, 2020 to October 23, 2020 was conducted. The HA visit notes indicated the following visits were made: a. October 4, 2020 to October 10, 2020, three HA visits were ordered, two HA visits were made. b. October 11, 2020 to October 17, 2020, three HA visits were ordered, two HA visits were made. 2. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 6, 2020, with a certification period of December 6, 2020 to March 5, 2021. Patient 5 had diagnoses that included deep vein thrombosis (DVT-a blood clot in a vein lying deep below the skin, especially in the legs). A review of Patient 5's plan of care/physician's order dated December 6, 2020, indicated the following: a. "Frequency of visit: SN [Skilled Nurse] 2 [two] x [times]/[per] week and as needed for crisis intervention and symptom management." b. "Frequency of visit: CHHA [Certified Home Health Aide] 2 [two] x [times]/[per]week for personal care and assistance with ADLs [activities of daily living]." c. "Frequency of visit: SC [Spiritual Counselor] 1 [one] x [time]/[per] month and as needed for spiritual support and services." d. "Frequency of visit: MSW [Medical Social Worker] 1 [one] x [time]/[per] month and as needed for psychosocial support and services." A review of Patient 5's SN visit notes from December 6, 2020 to February 6, 2021 was conducted. The SN visit notes indicated the following visits were made: a. December 20, 2020 to December 26, 2020, two SN visits were ordered, one SN visit was made. b. January 3, 2021 to January 9, 2021, two SN visits were ordered, one SN visit was made. c. January 10, 2021 to January 16, 2021, two SN visits were ordered, one SN visit was made. d. January 17, 2021 to January 23, 2021, two SN visits were ordered, one SN visit was made. e. January 24, 2021 to January 30, 2021, two SN visits were ordered, one SN visit was made. f. January 31, 2021 to February 6, 2021, two SN visits were ordered, one SN visit was made. A review of Patient 5's Hospice Aide (HA) visit notes from December 6, 2020 to February 6, 2021 was conducted. The HA visit notes indicated the following visits were made: a. December 27, 2020 to January 2, 2021, two HA visits were ordered, one HA visit was made. b. January 3, 2021 to January 9, 2021, two HA visits were ordered, one HA visit was made. c. January 10, 2021 to January 16, 2021, two HA visits were ordered, one HA visit was made. d. January 17, 2021 to January 23, 2021, two HA visits were ordered, one HA visit was made. e. January 24, 2021 to January 30, 2021, two HA visits were ordered, one HA visit was made. f. January 31, 2021 to February 6, 2021, two HA visits were ordered, zero HA visits were made. A review of Patient 5's SC visit notes from December 6, 2020 to February 6, 2021 was conducted. An initial spiritual assessment visit was conducted on December 7, 2020. There was no documented evidence to show any additional SC visits had been made. A review of Patient 5's MSW visit notes from December 6, 2020 to February 6, 2021 was conducted. An initial psychosocial assessment visit was conducted on December 14, 2020. There was no documented evidence to show any additional MSW visits had been made. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 from 12:22 PM to 12:47 PM, the DPCSD verified the HA did not make visits to Patient 2 as ordered. The DPCSD verified the SN, HA, SC and MSW did not make visits to Patient 5 as ordered. The DPCSD stated the SN, HA, SC and MSW were to follow the physician's order for visit frequencies. The DPCSD stated if the visit frequency needed to change the clinician was supposed to call the office so a new order could be obtained and the care plan updated. A review of the agency's policy and procedure titled, "The Plan of Care," dated April 2013, indicated the following: "Policy: ...The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. Procedure: ...The plan of care will identify the patient's needs and services to meet those needs...It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs. The written plan of care will contain, but will not be limited to, the following: Frequency and type of services Physician ... orders Care provided to the patient will be in accordance with the plan of care."
L0545
L0545	35183 Based on interview and record review, the agency failed to develop an individualized plan of care for four of six sampled patients (Patients 3, 4, 5 and 6) when: 1. For Patient 3, there were no physician's orders for Skilled Nursing (SN), Hospice Aide (HA), Spiritual Counselor (SC) or Medical Social Worker (MSW) visits. 2. For Patient 4, a Licensed Vocational Nurse (LVN) conducted a pre-admission assessment in the patients' home, without a physician's order. 3. For Patient 5, a Licensed Vocational Nurse (LVN) conducted a pre-admission assessment in the patients' home, without a physician's order. 4. For Patient 6, a Licensed Vocational Nurse (LVN) conducted a pre-admission assessment in the patients' home without a physician's order and there was no physician's order for Medical Social Worker (MSW) visits. This failure resulted in Patients 3, 4, 5 and 6 receiving care and services without a physician's clinical oversight. Findings: 1. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 5, 2020, with a certification period of September 5, 2020 to December 3, 2020 and a recertification period of December 4, 2020 to March 3, 2021. Patient 3 had diagnoses that included hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone). A review of Hospice Aide (HA) visit notes for the certification period of September 5, 2020 to December 3, 2020 was conducted. The HA made visits to Patient 3 on the following dates: a. September 9, 11, 14, 16, 18, 21, 25, 28 and 30, 2020 b. October 2, 5, 7, 9, 12, 14, 16, 19, 21, 23, 26, 28 and 30, 2020 c. November 5, 10, 12, 14, 17, 19, 21, 24 and 28, 2020 d. December 1 and 3, 2020 A review of Patient 3's physician's orders for the certification period of September 5, 2020 to December 3, 2020 was conducted. There was no documented evidence to show a physician's order for HA visits. A review of Spiritual Counselor (SC) visit notes for the certification period of September 5, 2020 to December 3, 2020 was conducted. The SC made a visit to Patient 3 on October 27, 2020. A review of Patient 3's physician's orders for the certification period of September 5, 2020 to December 3, 2020 was conducted. There was no documented evidence to show a physician's order for the SC visit. A review of Medical Social Worker (MSW) visit notes for the certification period of September 5, 2020 to December 3, 2020 was conducted. The MSW made a visit to Patient 3 on November 24, 2020. A review of Patient 3's physician's orders for the certification period of September 5, 2020 to December 3, 2020 was conducted. There was no documented evidence to show a physician's order for the MSW visit. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 at 12:28 PM, the DPCSD stated there was no physician's order for the HA, SC or MSW to make visits to Patient 3 and provide services. The DPCSD verified the HA, SC and MSW made visits to Patient 3 without a physician's order. The DPCSD stated he did not know why an order had not been obtained before the HA, SC and MSW provided services. A review of Skilled Nursing (SN) visit notes for the recertification period of December 4, 2020 to March 3, 2021 was conducted. The SN made visits to Patient 3 on the following dates: a. December 8, 11, 15, 24 and 31, 2020 b. January 7, 12, 21 and 26, 2021 c. February 4 and 10, 2021 A review of Patient 3's physician's orders for the recertification period of December 4, 2020 to March 3, 2021 was conducted. There was no documented evidence to show a physician's order for SN visits. A review of Hospice Aide (HA) visit notes for the recertification period of December 4, 2020 to March 3, 2021 was conducted. The HA made visits to Patient 3 on the following dates: a. December 5, 8, 10, 15, 17, 19, 22, 24, 26, 29 and 31, 2020 b. January 5, 7, 11, 13, 15, 18, 20, 22, 25, 27 and 29, 2021 c. February 1, 3, 4 and 9, 2021 A review of Patient 3's physician's orders for the recertification period of December 4, 2020 to March 3, 2021 was conducted. There was no documented evidence to show a physician's order for HA visits. A review of Spiritual Counselor (SC) visit notes for the certification period of December 4, 2020 to March 3, 2021 was conducted. The SC made visits to Patient 3 on December 22, 2020 and February 8, 2021. A review of Patient 3's physician's orders for the recertification period of December 4, 2020 to March 3, 2021 was conducted. There was no documented evidence to show a physician's order for the SC visits. A review of Medical Social Worker (MSW) visit notes for the recertification period of December 4, 2020 to March 3, 2021 was conducted. The MSW made visits to Patient 3 on December 22, 2020, January 19, 2021 and February 15, 2021. A review of Patient 3's physician's orders for the certification period of December 4, 2020 to March 3, 2021 was conducted. There was no documented evidence to show a physician's order for the MSW visits. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 at 12:28 PM, the DPCSD stated there was no physician's order for the SN, HA, SC or MSW to make visits to Patient 3 and provide services. The DPCSD verified the SN, HA, SC and MSW made visits to Patient 3 without a physician's order. The DPCSD stated he did not know why an order had not been obtained before the SN, HA, SC and MSW provided services. 2. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 9, 2021, with a certification period of January 9, 2021 to March 9, 2021. Patient 4 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 4's election of hospice care, dated January 8, 2021, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective January 8, 2021." A review of Patient 4's initial admission assessment, conducted by a Registered Nurse (RN), indicated a visit date of January 9, 2021. A review of a Licensed Vocational Nurse's (LVN 4) visit note, dated January 8, 2021, was conducted. The LVN visit note indicated it was a "Pre-Admit Eval [evaluation]" and was dated one day prior to the RN's initial admission assessment. A review of Patient 4's physician's orders for the certification period of January 9, 2021 to March 9, 2021 was conducted. There was no documented evidence to show a physician's order for the LVN "Pre-Admit Eval." During an interview with LVN 4 on February 11, 2021 at 1:47 PM, LVN 4 stated she had conducted a pre-admit evaluation on January 8, 2021 for Patient 4. LVN 4 stated a pre-admit evaluation consisted of an assessment of the patient's immediate needs. LVN 4 stated she evaluated the durable medical equipment the patient needed and called in a verbal order. LVN 4 stated she reviewed all the patient's medications including the discharge medication list. LVN 4 stated she created the patient's medication profile and called the nurse practitioner to review the medications and receive verbal orders. LVN 4 stated she would call the pharmacy for any refills of medications the patient needed. LVN 4 stated she would check over the patient's skin to see if there were any issues. LVN 4 stated the agency had an LVN go out and conduct a pre-admit evaluation when an RN was not available to do the admission. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 at 12:40 PM, the DPCSD stated there was no physician's order for Patient 4's LVN pre-admit evaluation visit. The DPCSD stated a physician's order should have been obtained but it was not. The DPCSD stated the agency had difficulty in getting RNs to work on weekends, holidays and after hours. The DPCSD stated an LVN would be scheduled for a pre-admit evaluation visit to address the patient and family's immediate care needs until the agency could send an RN. 3. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 6, 2020, with a certification period of December 6, 2020 to March 5, 2021. Patient 5 had diagnoses that included deep vein thrombosis (DVT-a blood clot in a vein lying deep below the skin, especially in the legs). A review of Patient 5's election of hospice care, dated December 4, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective December 4, 2020." A review of Patient 5's initial admission assessment, conducted by a Registered Nurse (RN), indicated a visit date of December 6, 2020. A review of a Licensed Vocational Nurse's (LVN 5) visit note, dated December 5, 2020, was conducted. The LVN visit note indicated it was a "Pre-Admit Eval [evaluation]" and was dated one day prior to the RN's initial admission assessment. A review of Patient 5's physician's orders for the certification period of December 6, 2020 to March 5, 2021 was conducted. There was no documented evidence to show a physician's order for the LVN "Pre-Admit Eval." During an interview with LVN 5 on February 10, 2021 at 10:10 AM, LVN 5 stated she had conducted a pre-admit evaluation on December 5, 2020 for Patient 5. LVN 5 stated she assessed the patient and reviewed the medications, including the discharge medications. LVN 5 stated she discussed the medications over the phone with the physician, received verbal orders and filled out the medication profile for Patient 5. LVN 5 assessed Patient 5's need for durable medical equipment and called in verbal orders for needed equipment. LVN 5 stated the agency had an LVN go out and conduct a pre-admit evaluation when an RN was not available to do the admission. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 at 12:47 PM, the DPCSD stated there was no physician's order for Patient 5's LVN pre-admit evaluation visit. The DPCSD stated a physician's order should have been obtained but it was not. The DPCSD stated the agency had difficulty in getting RNs to work on weekends, holidays and after hours. The DPCSD stated an LVN would be scheduled for a pre-admit evaluation visit to address the patient and family's immediate care needs until the agency could send an RN. 4. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 10, 2020, with a certification period of November 10, 2020 to January 27, 2021. Patient 6 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 6's election of hospice care, dated November 7, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective November 7, 2020." A review of Patient 6's initial admission assessment, conducted by a Registered Nurse (RN), indicated a visit date of November 10, 2020. A review of a Licensed Vocational Nurse's (LVN 6) visit note, dated November 9, 2020, was conducted. The LVN visit note indicated it was a "Pre-Admit Eval [evaluation]" and was dated one day prior to the RN's initial admission assessment. A review of Patient 6's physician's orders for the certification period of November 10, 2020 to January 27, 2021 was conducted. There was no documented evidence to show a physician's order for the LVN "Pre-Admit Eval." During an interview with LVN 6 on February 11, 2021 at 1:14 PM, LVN 6 stated she had conducted a pre-admit evaluation on November 9, 2020 for Patient 6. LVN 6 stated she checked on the patient and assessed the patient's immediate needs. LVN 6 stated she reviewed all the medications the patient was taking, called the nurse practitioner to review the medications and obtain verbal orders. LVN 6 stated she created Patient 6's medication profile. LVN 6 stated she assessed Patient 6's need for durable medical equipment and called for a verbal order if any equipment was needed. LVN 6 stated, "Partial admissions are common practice here and I have done a few." During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 at 12:56 PM, the DPCSD stated there was no physician's order for Patient 6's LVN pre-admit evaluation visit. The DPCSD stated a physician's order should have been obtained but it was not. The DPCSD stated the agency had difficulty in getting RNs to work on weekends, holidays and after hours. The DPCSD stated an LVN would be scheduled for a pre-admit evaluation visit to address the patient and family's immediate care needs until the agency could send an RN. A review of Medical Social Worker (MSW) visit notes for the recertification period of January 28, 2021 to April 27, 2021 was conducted. The MSW made a visit to Patient 6 on February 10, 2021. A review of Patient 6's physician's orders for the certification period of January 28, 2021 to April 27, 2021 was conducted. There was no documented evidence to show a physician's order for the MSW visit. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 at 12:56 PM, the DPCSD stated there was no physician's order for the MSW to make a visit to Patient 6 and provide services. The DPCSD verified the MSW made a visit to Patient 6 without a physician's order. The DPCSD stated he did not know why an order had not been obtained before the MSW provided services. A review of the agency's policy and procedure titled, "Verification of Physician Orders," dated April 2013, indicated, "Orders will be obtained from a licensed physician ... for care and services to be provided to hospice patients." A review of the agency's policy and procedure titled, "The Plan of Care," dated April 2013, indicated the following: "Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. Procedure: Orders for the start of care will be verbally received by the Case Manager (or hospice registered nurse) from the attending physician ... and documented on the plan of care/physician order form. The plan of care will identify the patient's needs and services to meet those needs ... It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs. The plan of care will be provided to both the attending physician and the hospice Medical Director for approval of verbal orders ... Care decisions and services to be provided will be made as a result of the care planning process ... The written plan of care will contain, but will not be limited to, the following: Frequency and type of services Physician ... orders."
L0648
L0648	35183 The hospice agency failed to ensure the Condition of Participation L 648 418.100: Organization and administration of services was in compliance as follows: Based on interview and record review, the agency failed to provide nursing services in accordance with the nurse practice act (Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) [Chapter 5, Section II: Assessment/ Implementation]) for six of six sampled patients (Patients 1, 2, 3, 4, 5 and 6) when Licensed Vocational Nurses (LVN) assessed immediate patient needs, reconciled (a process of creating the most accurate list possible of all medications a patient is taking - including drug name, dosage, frequency, and route - and comparing that list against the physician's orders) all patient medications and assessed durable medical equipment (such as: wheelchairs, hospital beds, canes, crutches and walkers) requirements, before a Registered Nurse (RN) had assessed and admitted the patients to the hospice agency. (Refer to L 652) The cumulative effect of these systemic practices resulted in the potential to cause deficient palliative (to make the effects of a disease less severe) interventions to mitigate (ease) suffering, inaccurate medication profiles and missed durable equipment needs.
L0652
L0652	35183 CA00714103 Based on interview and record review, the agency failed to provide nursing services in accordance with the nurse practice act (Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) [Chapter 5, Section II: Assessment/ Implementation]) for six of six sampled patients (Patients 1, 2, 3, 4, 5 and 6) when Licensed Vocational Nurses (LVN) assessed immediate patient needs, reconciled (a process of creating the most accurate list possible of all medications a patient is taking - including drug name, dosage, frequency, and route - and comparing that list against the physician's orders) all patient medications and assessed durable medical equipment (such as: wheelchairs, hospital beds, canes, crutches and walkers) requirements, before a Registered Nurse (RN) had assessed and admitted the patients to the hospice agency. This failure had the potential to cause deficient palliative (to make the effects of a disease less severe) interventions to mitigate (ease) suffering, inaccurate medication profiles and missed durable equipment needs. Findings: Licensed Vocational Nurse Scope of Practice for the State of California Board of Vocational Nursing 2518.5 (a) (Chapter 5, Section II: Assessment/Implementation): Nursing assessment is defined as a collection of data. The LVN may assist in the collection of the data during the assessment process. Validation of assessment data, however, must be done by an RN. Implementation: The LVN may not independently determine or initiate a course of action. 1. A review of Patient 1's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 18, 2020, with a certification period of September 18, 2020 to December 16, 2020. Patient 1 had diagnoses that included cancer of the jaw. Patient 1 transferred to another hospice agency on September 24, 2020. A review of Patient 1's election of hospice care, dated September 17, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 17, 2020." A review of Patient 1's initial admission assessment, conducted by a Registered Nurse (RN), indicated a visit date of September 21, 2020. A review of a Licensed Vocational Nurse's (LVN 3) visit note, dated September 18, 2020, was conducted. The LVN visit note indicated it was a "Pre-Admit Eval [evaluation]" and was dated three days prior to the RN's initial admission assessment. During a telephone interview with Patient 1's daughter on October 14, 2020 at 3 PM, Patient 1's daughter stated, "We have never done hospice before and we thought someone would explain the process to us, but they did not. They said they would be there at the house. She was an LVN not an RN. She [LVN 3] did not have pain medication for my mom when she got home from the hospital. The nurse [LVN 3] didn't check our mom at all. We did not know how to move my mom or do diaper changes. They kept saying they didn't have RN's for the weekend." During an interview with LVN 3 on February 11, 2021 at 10:08 AM, LVN 3 stated she had conducted a pre-admit evaluation on September 18, 2020 for Patient 1. LVN 3 stated she had assessed the patient's immediate care needs. LVN 3 stated she evaluated the durable medical equipment the patient needed and would call in a verbal order for any needed equipment. LVN 3 stated she reviewed all the patient's medications including the discharge medication list. LVN 3 stated she created the patient's medication profile and called the physician to review the medications and receive verbal orders. LVN 3 stated, "At the time, I was not supposed to order medications [order at pharmacy to fill a prescription] for the patient. I did not order morphine [a pain medication]. The family had pain medication to use. If they had not had the pain medication, I would ordered it." LVN 3 stated the agency had an LVN go out and conduct a pre-admit evaluation when an RN was not available to do the admission. 2. A review of Patient 2's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of October 3, 2020, with a certification period of October 3, 2020 to December 31, 2020. Patient 2 had diagnoses that included end stage renal disease (the kidneys stop functioning). Patient 2 passed away on October 23, 2020. A review of Patient 2's election of hospice care, dated September 29, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 29, 2020." A review of Patient 2's initial admission assessment, conducted by a Registered Nurse (RN), indicated a visit date of October 5, 2020. A review of a Licensed Vocational Nurse's (LVN 1) visit note, dated October 3, 2020, was conducted. The LVN visit note indicated it was a "Pre-Admit Eval [evaluation]" and was dated two days prior to the RN's initial admission assessment. During an interview with LVN 1 on February 11, 2021 at 10:20 AM, LVN 1 stated she had conducted a pre-admit evaluation on October 3, 2020 for Patient 2. LVN 1 stated she asked for discharge documentation to review and conducted a head to toe assessment. LVN 1 stated made sure to see if Patient 2 had wounds and assessed if Patient 2 was stable or in distress. LVN 1 stated she answered any questions family had and reviewed the hospice paperwork. LVN 1 stated she reviewed the medications in the home the patient was taking and reviewed the medications from the discharge paperwork. LVN 1 stated she notified the physician, who was assigned to that patient, about all the medications the patient was taking and gave the physician a history of Patient 2. LVN 1 stated she asked what medications the doctor wanted to continue and what medications the doctor wanted to discontinue. LVN 1 stated she created the medication profile for Patient 2 and provided medication teaching with the family. LVN 1 stated she notified the pharmacy of Patient 2's new medications and the medication profile. LVN 1 stated she assessed the need for durable medical equipment. LVN 1 stated, "I think in the future, if they may need something in the future. I assess the future needs for the patient." LVN 1 stated, "I try to give as much education as I can, because the family is scared." During an interview with a Registered Nurse (RN 2) on February 11, 2021 at 1:31 PM, RN 2 stated she did the initial admission assessment for Patient 2 on October 5, 2020. RN 2 stated she checked to see if the medications had been delivered and looked at the medications LVN 1 had already put on the medication profile. RN 2 stated LVN 1 did the medication reconciliation on October 3, 2020, "I just made sure it was done." RN 2 stated LVN pre-admit evaluations were normal practice for the agency. 3. A review of Patient 3's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of September 5, 2020, with a recertification period of December 4, 2020 to March 3, 2021. Patient 3 had diagnoses that included hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone). A review of Patient 3's election of hospice care, dated September 5, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective September 5, 2020." A review of Patient 3's initial admission assessment, conducted by a Registered Nurse (RN), indicated a visit date of September 8, 2020. A review of a Licensed Vocational Nurse's (LVN 1) visit note, dated September 5, 2020, was conducted. The LVN visit note indicated it was a "Pre-Admit Eval [evaluation]" and was dated three days prior to the RN's initial admission assessment. During a home visit on February 10, 2021 with a Licensed Vocational Nurse (LVN 5) and in the presence of Patient 3's daughter-in-law, an observation of Patient 3's actual medication bottles available in the home were compared with Patient 3's Medication Profile (MP - a current list of all medications prescribed for a specific patient). During an observation and concurrent interview with Patient 3's daughter-n-law and LVN 5 on February 10, 2021 at 10:57 AM, LVN 5 supplied a bottle of levothyroxine (a medication that replaces thyroid hormone) 25 mcg (micrograms-a unit of measure), take one tablet by mouth every day. Patient 3's MP indicated levothyroxine 250 mcg (10 times the amount indicated on the prescription bottle), take one tablet, oral (by mouth) daily. LVN 5 verified Patient 3's prescription bottle's label indicated 25 mcg and Patient 3's MP indicated 250 mcg. Patient 3's daughter-in-law stated she followed the instructions on the prescription bottle's label. A review of Patient 3's MP indicated the levothyroxine 250 mcg had been entered into Patient 3's MP on September 5, 2020. The same date as LVN 1's pre-admit evaluation. During an interview with LVN 1 on February 11, 2021 at 10:20 AM, LVN 1 stated she had conducted a pre-admit evaluation on September 5, 2020 for Patient 3. LVN 1 stated she asked for discharge documentation to review and conducted a head to toe assessment. LVN 1 stated made sure to see if Patient 3 had wounds and assessed if Patient 3 was stable or in distress. LVN 1 stated she answered any questions family had and reviewed the hospice paperwork. LVN 1 stated she reviewed the medications in the home the patient was taking and reviewed the medications from the discharge paperwork. LVN 1 stated she notified the physician, who was assigned to that patient, about all the medications the patient was taking and gave the physician a history of Patient 3. LVN 1 stated she asked what medications the doctor wanted to continue and what medications the doctor wanted to discontinue. LVN 1 stated she created the medication profile for Patient 3 and provided medication teaching with the family. LVN 1 stated she notified the pharmacy of Patient 3's new medications and the medication profile. LVN 1 stated she assessed the need for durable medical equipment. LVN 1 stated, "I think in the future, if they may need something in the future. I assess the future needs for the patient." LVN 1 stated, "I try to give as much education as I can, because the family is scared." During an interview with a Registered Nurse (RN 1) on February 9, 2021 at 10:38 AM, RN 1 stated she had conducted Patient 3's initial admission assessment on September 8, 2020. RN 1 stated she did not conduct a medication reconciliation at her admissions if an LVN had conducted a pre-admit evaluation. RN 1 stated, "The LVN has already done it, I'm not going to do it all over again." 4. A review of Patient 4's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of January 9, 2021, with a certification period of January 9, 2021 to March 9, 2021. Patient 4 had diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 4's election of hospice care, dated January 8, 2021, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective January 8, 2021." A review of Patient 4's initial admission assessment, conducted by a Registered Nurse (RN), indicated a visit date of January 9, 2021. A review of a Licensed Vocational Nurse's (LVN 4) visit note, dated January 8, 2021, was conducted. The LVN visit note indicated it was a "Pre-Admit Eval [evaluation]" and was dated one day prior to the RN's initial admission assessment. During an interview with LVN 4 on February 11, 2021 at 1:47 PM, LVN 4 stated she had conducted a pre-admit evaluation on January 8, 2021 for Patient 4. LVN 4 stated a pre-admit evaluation consisted of an assessment of the patient's immediate needs. LVN 4 stated she evaluated the durable medical equipment the patient needed and called in a verbal order. LVN 4 stated she reviewed all the patient's medications including the discharge medication list. LVN 4 stated she created the patient's medication profile and called the nurse practitioner to review the medications and receive verbal orders. LVN 4 stated she would call the pharmacy for any refills of medications the patient needed. LVN 4 stated she would check over the patient's skin to see if there were any issues. LVN 4 stated the agency had an LVN go out and conduct a pre-admit evaluation when an RN was not available to do the admission. 5. A review of Patient 5's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of December 6, 2020, with a certification period of December 6, 2020 to March 5, 2021. Patient 5 had diagnoses that included deep vein thrombosis (DVT-a blood clot in a vein lying deep below the skin, especially in the legs). A review of Patient 5's election of hospice care, dated December 4, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective December 4, 2020." A review of Patient 5's initial admission assessment, conducted by a Registered Nurse (RN), indicated a visit date of December 6, 2020. A review of a Licensed Vocational Nurse's (LVN 5) visit note, dated December 5, 2020, was conducted. The LVN visit note indicated it was a "Pre-Admit Eval [evaluation]" and was dated one day prior to the RN's initial admission assessment. During a home visit on February 9, 2021 with a Registered Nurse (RN 1) and in the presence of Patient 5's daughter, an observation of Patient 5's actual medication bottles available in the home were compared with Patient 5's Medication Profile (MP - a current list of all medications prescribed for a specific patient). During an observation and concurrent interview with Patient 5's daughter and RN 1 on February 9, 2021 at 3:41 PM, Patient 5's daughter supplied a bottle of Eliquis (a medication that thins the blood to prevent blood clots) 5 mg (milligrams-a unit of measure), take one-half tablet by mouth two times a day (a total of 5 mg each day). Patient 5's MP indicated Eliquis 5 mg tablet, take 1.5 tablets, oral (by mouth), twice a day (a total of 15 mg each day). RN 1 verified Patient 5's prescription bottle's label indicated one-half tablet and Patient 5's MP indicated 1.5 tablets. Patient 5's daughter stated she followed the instructions on the prescription bottle's label and gave a half a tablet two times per day. Patient 5's daughter stated Patient 5 had been taking Eliquis half a tablet, two times a day, since September 2018. RN 1 stated the MP indicated too much Eliquis. A review of Patient 5's MP indicated the Eliquis 1.5 tablets, twice a day (a total of 15 mg each day) had been entered into Patient 5's MP on December 5, 2020. The same date as LVN 5's pre-admit evaluation. During an interview with LVN 5 on February 10, 2021 at 10:10 AM, LVN 5 stated she had conducted a pre-admit evaluation on December 5, 2020 for Patient 5. LVN 5 stated she assessed the patient and reviewed the medications, including the discharge medications. LVN 5 stated she discussed the medications over the phone with the physician, received verbal orders and filled out the medication profile for Patient 5. LVN 5 assessed Patient 5's need for durable medical equipment and called in verbal orders for needed equipment. LVN 5 stated the agency had an LVN go out and conduct a pre-admit evaluation when an RN was not available to do the admission. 6. A review of Patient 6's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 10, 2020, with a certification period of November 10, 2020 to January 27, 2021. Patient 6 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 6's election of hospice care, dated November 7, 2020, indicated, "I consent to [name of agency] to provide hospice care under the Medicare Hospice Benefit effective November 7, 2020." A review of Patient 6's initial admission assessment, conducted by a Registered Nurse (RN), indicated a visit date of November 10, 2020. A review of a Licensed Vocational Nurse's (LVN 6) visit note, dated November 9, 2020, was conducted. The LVN visit note indicated it was a "Pre-Admit Eval [evaluation]" and was dated one day prior to the RN's initial admission assessment. During an interview with LVN 6 on February 11, 2021 at 1:14 PM, LVN 6 stated she had conducted a pre-admit evaluation on November 9, 2020 for Patient 6. LVN 6 stated she checked on the patient and assessed the patient's immediate needs. LVN 6 stated she reviewed all the medications the patient was taking, called the nurse practitioner to review the medications and obtain verbal orders. LVN 6 stated she created Patient 6's medication profile. LVN 6 stated she assessed Patient 6's need for durable medical equipment and called for a verbal order if any equipment was needed. LVN 6 stated, "Partial admissions are common practice here and I have done a few." During an interview with a Registered Nurse (RN 2) on February 11, 2021 at 1:31 PM, RN 2 stated she did the initial admission assessment for Patient 6 on November 10, 2020. RN 2 stated she checked to see if the medications had been delivered and looked at the medications LVN 6 had already put on the medication profile. RN 2 stated LVN 6 did the medication reconciliation on November 9, 2020, "I just made sure it was done." RN 2 stated LVN pre-admit evaluations were normal practice for the agency. During an interview with the Director of Patient Care Services Designee (DPCSD), in the presence of the Administrator (Admin), on February 16, 2021 at 1:15 PM, the DPCSD stated the agency had been having difficulty in getting RNs to work on weekends, holidays and after hours. The DPCSD stated the agency had decided to implement a pre-admission program using LVNs. The DPCSD stated this pre-admission was a stop gap measure until an RN could be scheduled for the admission. The DPCSD stated after reviewing the LVN's scope of practice, he realized the agency had asked the LVNs to work outside of their scope and placed the agency's patients at risk. A review of the agency's policy and procedure titled, "Listing of Services Provided," dated 2013, indicated, "Purpose: To ensure that services, whether provided directly or under contractual agreement, adhere to hospice policies and procedures and professional management accountability. Procedure: Services will be provided as listed below: Registered Nurse, Licensed practical/vocational nurse..." A review of the agency's policy and procedure titled, "Licensed Practical/Vocational Nurse Job Description," dated April 2013, indicated the following: "Job Description Summary: The Licensed Practical/Vocational Nurse is responsible for providing direct patient care under the supervision of a registered nurse... Essential Job Functions/Responsibilities: Provides direct patient care as defined in State Nurse Practice Act. Position Qualifications: Complies will accepted professional standards and practice."